Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Multisystem Trauma with Hemorrhagic Shock

Patient Demographics

• Age: 34 years
• Sex: Male
• Occupation: Delivery driver

Mechanism of Injury

High-speed motor vehicle collision. Unrestrained driver, vehicle rollover with partial ejection. Estimated speed 55 mph. Prolonged extrication (25 minutes). GCS at scene: 10.

Prehospital Care

• Cervical spine immobilization
• 2 large-bore IVs, 500mL NS initiated
• Oxygen via non-rebreather
• EMS blood pressure: 72/palp
• EMS heart rate: 138 bpm

Trauma Team Activation

Level 1 Trauma Activation Criteria Met:

• GCS <14
• SBP <90
• Ejection from vehicle
• Prolonged extrication

Primary Survey (ABCDE)

Airway with C-Spine Protection:

• Speaking incoherently
• Blood in oropharynx
• Cervical collar in place
• Airway at risk - prepare for RSI

Breathing:

• RR 28, labored
• Decreased breath sounds on LEFT
• Dullness to percussion on LEFT
• Trachea midline
• SpO2 88% on NRB

Circulation:

• HR 142, weak and thready
• BP 68/palp
• Capillary refill >4 seconds
• Cool, mottled extremities
• FAST positive - free fluid in Morrison's pouch
• Pelvis stable on single compression

Disability:

• GCS 9 (E2V3M4)
• Pupils: 4mm bilaterally, reactive
• Glucose: 118 mg/dL
• Moves all extremities to pain

Exposure:

• Open deformity right femur
• Large scalp laceration
• Multiple abrasions
• Core temp: 35.8C

Immediate Life Threats Identified

1. Left hemothorax - decreasing breath sounds, dull to percussion
2. Hemorrhagic shock (Class III-IV) - hypotension, tachycardia, AMS
3. Intra-abdominal hemorrhage - positive FAST
4. Open femur fracture - ongoing blood loss

Resuscitation

Airway:

• RSI performed with inline stabilization
• Etomidate 20mg + Succinylcholine 100mg
• 7.5 ETT placed, confirmed with ETCO2
• Post-intubation CXR: ETT 3cm above carina

Breathing:

• Left tube thoracostomy: 1200mL blood immediately drained
• Lung re-expanded
• SpO2 improved to 96%

Circulation - Damage Control Resuscitation:

• Massive Transfusion Protocol activated
• Blood products: 1:1:1 ratio (PRBC:FFP:Platelets)
• First cooler: 6 units PRBC, 6 units FFP, 1 pack platelets
• Tranexamic Acid (TXA) 1g IV bolus (within 3 hours of injury)
• Permissive hypotension target: SBP 80-90 mmHg
• Minimize crystalloid - only 1L NS total
• Calcium gluconate 1g for citrate toxicity prevention

Hemorrhage Control:

• Tourniquet applied to right thigh above femur fracture
• Pressure to scalp laceration

Secondary Survey (Abbreviated - patient unstable)

Head: Large stellate laceration, no skull depression Face: Periorbital ecchymosis bilateral Neck: C-collar, no step-offs Chest: Tube thoracostomy in place, equal breath sounds Abdomen: Distended, tender, positive FAST Pelvis: Stable Extremities: Open right femur fracture, compartments soft Back (log roll): No step-offs, no wounds

Imaging

Portable CXR:

• ETT in good position
• Left chest tube in place
• Lung re-expanded
• Multiple left-sided rib fractures

Pelvis XR:

• No pelvic fracture

FAST:

• Positive: Free fluid in Morrison's pouch and pelvis
• No pericardial fluid

Hemorrhagic Shock Classification

Operative Management

Decision: Emergent laparotomy

• Persistent hypotension despite MTP
• Positive FAST with abdominal distension
• Hemothorax output decreasing (not surgical threshold)

OR Findings:

• Grade IV liver laceration (controlled with packing)
• Grade III splenic laceration (splenectomy performed)
• 2L hemoperitoneum
• Damage control laparotomy - abdomen left open

Orthopedic Surgery:

• External fixation of right femur fracture
• Definitive fixation delayed until stable

Post-Operative Course

ICU Admission:

• Continued MTP until INR <1.5, fibrinogen >150
• Weaned from vasopressors day 2
• Extubated day 3
• Abdominal closure day 4
• Femur ORIF day 5

Total Blood Products (first 24 hours):

• 18 units PRBC
• 16 units FFP
• 3 packs platelets
• 10 units cryoprecipitate

Teaching Points

1. Damage Control Resuscitation: 1:1:1 ratio, permissive hypotension, minimize crystalloid
2. TXA within 3 hours: Reduces mortality in bleeding trauma
3. Tube thoracostomy thresholds: Initial >1500mL or ongoing >200mL/hr = OR
4. FAST guides but doesn't replace clinical judgment: Unstable + positive FAST = OR
5. Damage control surgery: Control hemorrhage, prevent lethal triad, definitive repair later
6. Lethal Triad: Hypothermia, acidosis, coagulopathy - prevent/correct aggressively

Clinical Image

Image Description: Contrast-enhanced CT of the abdomen demonstrating a high-grade liver laceration with active extravasation and hemoperitoneum, consistent with traumatic hepatic injury.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Andrew Dixon. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/liver-laceration-trauma

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